1312.1(c)
CLINTON PUBLIC SCHOOLS
Clinton, Connecticut

Request for Review of Educational Material

PRINT MATERIAL

Author		______________________________________

Title		______________________________________

Publisher	______________________________________

NON-PRINT MATERIAL

	Title			______________________________________

	Producer		______________________________________

	Audiovisual Software	_________________________

	Computer Software	_________________________

1.  To what in the work do you object?  Please cite specific passages by page, frame, slide, film, etc.  Please explain your specific objection/s.

      ______________________________________________________________________________

      ______________________________________________________________________________


2.  Did you read, view, hear the entire work?  _________  If not, what parts did you read, view or hear?

______________________________________________________________________________

______________________________________________________________________________


3.  Do you believe that there is anything positive about the material?  Please explain.

______________________________________________________________________________

______________________________________________________________________________


4.  For what age group do you believe this work may have value?

______________________________________________________________________________

______________________________________________________________________________


5.  Are you aware of the judgment of this work by literary/media critics?

______________________________________________________________________________

______________________________________________________________________________


6.  What are the educational purposes for using this work?

______________________________________________________________________________

______________________________________________________________________________


 

Form for Review of Educational Material					1312.1(d)




Page 2

7.	What do you believe is the theme of this work?

___________________________________________________________________________

___________________________________________________________________________


8.  Other comments:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________




____________________________
Signature of Complainant

____________________________
Date

____________________________
School Child Attends


FOR OFFICIAL USE ONLY - COMPLAINANT SHOULD NOT COMPLETE

Written notification received by principal	____________________________
                                                 date
Initial meeting among principal, staff member, and complainant	____________________________
                                                                           date
“Request for Review” form received by principal	____________________________
                                                           date
Review Committee meeting	____________________________
                                         date
Report forwarded to Superintendent	____________________________
                                         date
Complainant notified	____________________________
                                         date